From the Guidelines
The diagnostic approach for dizziness should start with a thorough clinical evaluation, including a detailed history and physical examination, to identify potential causes and determine the need for imaging studies.
Key Components of the Diagnostic Approach
- Clinical Triage: Patients with isolated dizziness, without vertigo, ataxia, or other neurologic deficits, have a low probability of detecting an abnormality on CT or MRI, with yields of less than 1% and 4%, respectively 1.
- Bedside Tests: Various bedside tests, such as the HINTS examination, have been developed to distinguish between benign and central causes of dizziness, and can help determine the need for imaging studies 1.
- Imaging Studies: Imaging studies, such as CT or MRI, may be necessary in patients with atypical features, lack of response to treatment, or suspected central causes of dizziness, such as stroke or multiple sclerosis 1.
- Specific Diagnostic Criteria: Specific diagnostic criteria, such as the Dix-Hallpike maneuver, can help diagnose benign paroxysmal positional vertigo (BPPV) and other causes of dizziness 1.
Approach to Specific Variants of Dizziness
- Brief Episodic Vertigo: In patients with brief episodic vertigo triggered by specific head movements, BPPV is the most likely cause, and no imaging is indicated unless there are atypical features 1.
- Acute Persistent Vertigo: In patients with acute persistent vertigo and a normal neurologic examination, vestibular neuritis is the most likely diagnosis, and imaging may not be necessary if the HINTS examination is negative 1.
- Nonspecific Dizziness: In patients with nonspecific dizziness without vertigo, ataxia, or other neurologic deficits, the diagnostic yield of imaging studies is low, and clinical triage is critical to determine the need for further evaluation 1.
From the Research
Diagnostic Approach for Dizziness
The diagnostic approach for dizziness involves a thorough evaluation of the patient's symptoms, medical history, and physical examination to determine the underlying cause. The following steps can be taken:
- Categorize patients into three groups based on timing and triggers: acute vestibular syndrome, spontaneous episodic vestibular syndrome, and triggered episodic vestibular syndrome 2, 3
- Use the patient's history to guide a focused physical examination, including evaluation for nystagmus, the Dix-Hallpike maneuver, and orthostatic blood pressure testing 4, 5
- Assess for central and peripheral causes of vertigo, using imaging techniques and laboratory testing as needed 5, 6
- Develop a differential diagnosis based on the patient's symptoms and physical examination findings, and tailor the treatment approach accordingly 2, 4, 5, 3
Key Components of the Diagnostic Approach
- Timing and triggers: Use the timing and triggers of the patient's symptoms to guide the diagnostic approach 2, 3
- Physical examination: Perform a thorough physical examination, including evaluation for nystagmus, the Dix-Hallpike maneuver, and orthostatic blood pressure testing 4, 5
- Imaging and laboratory testing: Use imaging techniques and laboratory testing as needed to support the diagnosis 5, 6
- Differential diagnosis: Develop a differential diagnosis based on the patient's symptoms and physical examination findings, and tailor the treatment approach accordingly 2, 4, 5, 3
Common Causes of Dizziness
- Benign paroxysmal positional vertigo: A common cause of vertigo, which can be treated with the Epley maneuver or vestibular rehabilitation 4, 5
- Vestibular migraine: A common cause of episodic vertigo, which can be treated with vestibular rehabilitation and other targeted therapies 2, 3
- Posterior circulation strokes: A serious cause of vertigo, which requires prompt diagnosis and treatment 2, 3